REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SULTAN KUDARAT…) S.S.

CITY OF TACURONG……………….....)
x…………..………………………………….………………x

AFFIDAVIT
I, ADONIS SOLIDARIOS BESA, of legal age, Filipino, single
and a resident of Purok Pagkakaisa, Barangay Baluan, General
Santos City, after having been duly sworn to in accordance with
law, do hereby depose and say, that:

1. On December 20, 2017 at 12:00 in the afternoon,

while driving my motorcycle, I met an accident on my
way to Isulan, Sultan Kudarat from South Cotabato
when I was trying to evade a certain vehicle, I lost
control of the motorcycle and I fell down hitting
the shoulder of the road and turned turtle;
2. The incident resulted to heavy damages of my Alto-
800 motorcycle;
3. The incident also caused slight physical injuries on
some of my body parts which the same was attended;
4. The motorcycle was brought to the Traffic Station
of Isulan, Sultan Kudarat for security and
investigation;
5. That the accident was due to my own fault and
negligence;
6. I executed this affidavit in compliance with the
insurance claim;
7. I executed this affidavit freely and voluntarily and
hereby attest the veracity of the foregoing
declaration under pain of perjury and for whatever
legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this th day

of February, 2018 at Tacurong City, Sultan Kudarat, Philippines.

ADONIS SOLIDARIOS BESA

Affiant

th
SUBSCRIBED AND SWORN to before me this day of February,
2018 at Tacurong City, Sultan Kudarat, Philippines.